Enhanced Recovery After Surgery (ERAS) Spine Pathways and the Role of Perioperative Checklists.

Enhanced recovery after surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. ERAS pathways have been shown to help reduce complications, hospital length of stay (LOS), 30-day readmission rates, pain scores, and ultimately surgical costs, while improving patient satisfaction scores and outcomes in multiple surgical subspecialties [1-6]. Numerous specialties have implemented ERAS programs across the globe, providing a foundation for spine surgeons to begin the process themselves. Over the last few years, a significant number of papers have been addressing ERAS pathways for spinal surgery [7-19]. The majority have addressed the lumbar spine [9, 20-26]. The number of cervical ERAS pathways has been limited [27-29]. Many spine programs have begun the implementation of ERAS pathways, incorporating principles and interventions to various spine surgical procedures. Although differences in implementation across programs exist, there are a few common elements that promote a successful enhanced recovery approach [11, 16, 23, 25, 30-33]. All spinal ERAS pathways have three major elements, which are preoperative, perioperative, and postoperative phases. Within these phases some common elements include preoperative and intraoperative surgical checklists. Intraoperative checklist in addition to the "surgical time out" has been integrated into the workflow of most hospitals doing surgeries and have become a standard of care. The surgical checklist is designed to help reduce surgical errors and prevent wrong site/patient surgeries. Several surgical checklists have been developed throughout the years. Despite these safety protocols wrong site/level and other surgical errors continue to occur. Many cases of wrong level spine surgery (WLSS) still occur even when intraoperative imaging is performed [34, 35]. One survey reported that about 50% of spine surgeons have performed at least one WLSS during their career [36, 37]. Another survey reported that 36% of spine surgeons had performed at least one WLSS that was not recognized intraoperatively [38]. On a similar account, about 30% of spine surgery fellows have experienced wrong-site surgery [39]. From raw incidence rates, WLSS may seem rare, but these surveys show that the experience of WLSS is rather common among spine surgeons. WLSS is not yet a "never event." This may be due to poor quality of the intraoperative images, hindering subsequent level identification [34, 35, 38, 40]. Errors in interpretation of the imaging may also occur, including inconsistency in numbering vertebrae, inconsistency in landmark usage for level counting, and problems with numbering vertebrae due to lumbosacral transitional vertebrae (LSTV) and other anatomical variants [34, 38, 41-43]. This chapter will describe a framework for the development and implementation of ERAS pathway for patients undergoing spine surgery. In addition, we will propose preoperative imaging guidelines and a comprehensive spine surgical checklist to incorporate into the perioperative phase to help reduce further surgical errors and WLSS.

Fluoroscopic Guided Lumbar Erector Spinae (ESP) Field Blocks: A New Technique and Radiographic Analysis.

INTRODUCTION: Lumbar Erector Spinae (ESP) field blocks have become a common postoperative treatment for surgical pain. The use of long-acting medications like liposomal bupivacaine (Exparel) has become a major component of multimodal postsurgical pain control. Traditionally ESP injections have been performed using ultrasound (U/S) guidance by an anesthesiologist. Spine surgeons have begun to utilize these liposomal injections in their procedures for postoperative pain management. Our study describes a fluoroscopic guided ESP field block technique which provides reproducible muscular coverage and pain control for spine surgery. MATERIAL AND METHODS: Sixty patients undergoing single level lumbar fusion were treated preoperatively with bilateral fluoroscopically-guided lumbar erector spinae ESP field blocks with liposomal bupivacaine. We looked at 2 different injection locations involving the ESP or multifidus muscle fascial planes. The injections contained Iohexal, which was used to evaluate the coverage area of the injection. The levels of coverage were recorded, and postoperative pain control was measured immediately, postoperatively, and at 24 hours. RESULTS: Fluoroscopic field blocks at the L3-4 level were found to provide at least 4 levels of vertebral coverage rostral-caudally in both ESP and MF fascial planes. Pain was well controlled in both injection sites. CONCLUSIONS: Surgeon-administered fluoroscopic-guided ESP field blocks provided a reliable and consistent pattern of coverage with good postoperative pain control. This technique can be easily adopted by spine surgeons.

Complications of Anterior Cervical Discectomy and Fusion.

Anterior cervical discectomy and fusion (ACDF) is the most common surgery performed on the cervical spine, and the number of its cases has tripled over the last two decades. Although this intervention is typically safe and effective, it carries an inherent complication risk, which should not be underestimated. Improvements in surgical techniques and advances in interbody fusion devices and plating systems have certainly reduced the rate of postoperative morbidity, but despite such progress, surgeons need to beware consistently of the potential complications, inform the patient of their possibility, and have a management strategy as they develop. This review discusses postoperative morbidity encountered in recently reported large studies on ACDF and highlights the senior author's own single-surgeon experience with 2579 such procedures performed between 1998 and 2017. In his clinical series, which is the largest one reported to date, the overall complication rate was 7.0% (180 cases), and dysphagia (1.9% of cases), graft/hardware failures (1.3% of cases), and postoperative hematomas (0.9% of cases) were noted most frequently. Understanding of the risk and clinical impact of complications after ACDF is very important and every effort should be put on their possible avoidance and on appropriate management when they do occur.

Conservative Treatment and Percutaneous Pain Relief Techniques in Patients with Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations.

BACKGROUND: Degenerative lumbar spinal stenosis (LSS) is a progressive disease with potentially dangerous consequences that affect quality of life. Despite the detailed literature, natural history is unpredictable. This uncertainty presents a challenge making the correct management decisions, especially in patients with mild to moderate symptoms, regarding conservative or surgical treatment. This article focused on conservative treatment for degenerative LSS. METHODS: To standardize clinical practice worldwide as much as possible, the World Federation of Neurosurgical Societies Spine Committee held a consensus conference on conservative treatment for degenerative LSS. A team of experts in spinal disorders reviewed the literature on conservative treatment for degenerative LSS from 2008 to 2018 and drafted and voted on a number of statements. RESULTS: During 2 consensus meetings, 14 statements were voted on. The Committee agreed on the use of physical therapy for up to 3 months in cases with no neurologic symptoms. Initial conservative treatment could be applied without major complications in these cases. In patients with moderate to severe symptoms or with acute radicular deficits, surgical treatment is indicated. The efficacy of epidural injections is still debated, as it shows only limited benefit in patients with degenerative LSS. CONCLUSIONS: A conservative approach based on therapeutic exercise may be the first choice in patients with LSS except in the presence of significant neurologic deficits. Treatment with instrumental modalities or epidural injections is still debated. Further studies with standardization of outcome measures are needed to reach high-level evidence conclusions.

Case Report of Acquired Stuttering After Soccer-Related Concussion: Functional Magnetic Resonance Imaging as a Prognostic Tool.

BACKGROUND: Acquired stuttering has been reported resulting from various forms of traumatic brain injury. In stuttering patients, there has been an association with higher activity of right frontal operculum activity on functional magnetic resonance imaging (MRI). This report looked to identify any structural lesions in a patient with postconcussive stuttering after a head injury playing soccer. CASE DESCRIPTION: A 16-year-old girl presented with acquired stuttering after striking the back of her head during a soccer match. She did not lose consciousness. She complained of a mild headache, complained of blurred vision, and was slightly lethargic. The next morning, she was noted to have a significant problem with stuttering. Examination was remarkable for some mild occipital tenderness. Speech was noted to have significant stuttering. She was unable to sing without stuttering. Remaining neurologic examination was normal. Brain computed tomography scan and MRI were normal, with no evidence of any bleeding or contusions. Functional MRI was performed, and no increased activity was seen in the right frontal operculum. The patient was referred for speech therapy. Her symptoms continued for 6 weeks and slowly started to improve and resolved by 9 weeks after her accident. At 6 months, she had no residual speech problems. CONCLUSIONS: Stuttering can occur after mild to moderate head trauma. Patients with permanent stuttering have been found to have increased activity in the right frontal operculum. If no identifiable lesion can be seen, the stuttering may resolve spontaneously. Functional MRI maybe helpful in differentiating between permanent versus transient stuttering after head trauma.

Percutaneous vertebral augmentation: StabilitiT a new delivery system for vertebral fractures.

Percutaneous vertebral augmentation for compression fractures with bone cement has become an increasingly popular form of treatment. Various delivery techniques and bone cements have been developed. StabiliT Vertebral Augmentation System (DFINE Inc., San Jose, CA) is a unique radiofrequency (RF) based system which delivers an ultra-high viscosity bone cement. The patented StabiliT ER bone cement has an extended working time prior to RF warming. When delivered through this unique hydraulic system an on-demand ultra-high viscosity cement can be delivered into an osteotome created cavity resulting in a clinical procedure with the best qualities of both vertebroplasty and conventional balloon assisted kyphoplasty.

Clinical course and surgical management of massive cerebral infarction.

OBJECTIVE: Acute occlusion of the proximal middle cerebral artery (MCA) can lead to rapid development of fatal brain swelling and ischemic strokes. Decompressive surgery, if performed early in this subpopulation of patients, can reduce mortality and result in a favorable outcome. In this article, we describe our surgical approach for treating malignant MCA syndrome and compare it with other management strategies. METHODS: This is a retrospective review of patients who developed acute occlusion of the proximal MCA and underwent aggressive surgical decompression (large craniectomy, anterior temporal lobectomy, resection of infarcted tissue, and duraplasty). The outcome of this management strategy is compared with the previously published outcomes of hemicraniectomy and dural augmentation. RESULTS: Twelve patients were included in the study. The group consisted of six men and six women (mean age, 46.8 yr). Nine patients had right MCA stroke, and three had left MCA infarction. The causes of the strokes were cardioembolic, iatrogenic, small-vessel occlusive disease, and others. The interval between infarction and clinical evidence of herniation varied from 24 hours to 10 days. Two patients died, five were independent or had moderate disabilities, and five had severe disability. CONCLUSION: Surgical decompression consisting of a large craniectomy, anterior temporal lobectomy, resection of infarcted tissue, and duraplasty is beneficial to a significant number of patients with massive MCA stroke and clinical signs of herniation.